202250 - Deadly MOB while rigging pilot combination ladder

22 Nov 2022 MARS

In the early morning hours, a loaded tanker with seven metres of freeboard was approaching port at about 6.5 knots. There was a light wind and seas of approximately 1 metre. Visibility was good, but it was still dark; sunrise was in about one hour and 45 minutes. The air temperature was 15C and the sea water temperature was 16C.

The combination accommodation/pilot ladder was being rigged to allow pilot access. The Bosun and one other seaman were on deck for this task while the OOW monitored from the bridge. After lowering the accommodation ladder the Bosun and the seaman took off their lifejackets and safety harnesses/lines. They then rigged the pilot ladder, but they found that the lower platform of the accommodation ladder needed adjusting to be parallel with the water. The seaman went down the accommodation ladder without putting his lifejacket and safety harness back on. Neither the Bosun nor the OOW in the wheelhouse objected to this unsafe act.

The lower platform is held in position by a securing pin that passes through one of four sets of holes in the angle bracket. The angle of the platform is determined by which set of holes on the angle bracket the securing pin is passed through. Changing the angle of the platform after the accommodation ladder is lowered requires the operator to crouch down to reach and remove the securing pin with one hand while using the other hand to hold onto the rope attached to the platform to reposition it at the intended angle. They can then put the securing pin in the proper set of holes.


While performing this balancing act, the seaman lost his balance and fell overboard. The Bosun immediately reported an MOB on the port side to the bridge with his handheld VHF radio and then ran aft to throw a life buoy. He lost sight of the victim when he was about 100 metres astern of the vessel. Meanwhile, the Master ordered the rudder hard to starboard. In the flurry of events, the lighted MOB buoy mounted on the bridge wing was not released.

Within 12 minutes the vessel had completed a single turn manoeuvre and reached the position where the victim had fallen overboard. The rescue boat was ready to be launched, but was not used, since local search and rescue (SAR) units and the outbound pilot boat were already tasked to search for the victim. The pilot assigned to the vessel embarked to assist the Master and coordinate with local authorities. When the victim could not be found after three hours searching, the SAR mission was suspended.

Lessons learned

  • Actual Man Overboard (MOB) events are rather rare but when they happen, they are often serious or fatal for the victim. Numerous quick and decisive actions must be taken by the vessel’s crew. For this reason, realistic MOB exercises are regularly performed to imprint the actions into rote memory. In this case, many of those actions were performed well but two critical ones were not:
    • The vessel was turned to starboard for a port side MOB. Normally the vessel should always be turned to the same side as the victim to throw the stern clear of the victim.
    • The bridge wing lighted MOB buoy was not released. This should be an automatic gesture by the OOW in any real MOB situation
  • PPE, PPE, PPE. Every time someone works overboard they should be wearing a lifejacket and a well secured safety harness.
  • Look after yourself but also look after your mates! The victim decided to go down the accommodation ladder without his lifejacket and safety harness/line. Yet, both the OOW on the bridge watching the work and the Bosun acquiesced to this unsafe act.
  • If acrobatic acts are necessary to complete a task, that means the task should probably not be completed under those conditions.